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  • Purpura, Petechiae

    and Vasculitis

    UCSF Dermatology

    Last updated 9.17.10

  • Module Instructions

    The following module contains a number of

    green, underlined terms which are

    hyperlinked to the dermatology glossary, an

    illustrated interactive guide to clinical

    dermatology and dermatopathology.

    We encourage the learner to read all the

    hyperlinked information.

    http://missinglink.ucsf.edu/lm/DermatologyGlossary/index.html

  • Goals and Objectives

    The purpose of this module is to help medical students develop a clinical approach to the initial evaluation and treatment of patients with petechiae and purpura.

    After completing this module, the medical student will be able to: Identify and describe the morphology of petechiae and

    purpura

    Outline an initial diagnostic approach to petechiae or purpura

    Recognize patterns of petechiae that are concerning for life-threatening conditions

    Recognize palpable purpura as the hallmark lesion of leukocytoclastic vasculitis

    Name the common etiologies of vasculitides according to size of vessel affected

  • Purpura: The Basics

    The term Purpura is used to describe red-purple lesions that result from the extravasation of blood into the skin or mucous membranes

    Purpura may be palpable or non-palpable (flat/macular)

    Macular purpura is divided into two morphologies based on size: Petechiae: small lesions (< 3 mm)

    Ecchymoses: larger lesions (>5mm)

    The type of lesion present is usually indicative of the underlying pathogenesis: Macular purpura is typically non-inflammatory

    Palpable purpura is a sign of vascular inflammation (vasculitis)

    http://missinglink.ucsf.edu/lm/DermatologyGlossary/purpura.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/petechiae.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/ecchymosis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/vasculitis.html

  • Purpura: The Basics

    All forms do not blanch when pressed

    Diascopy refers to the use of a glass slide to apply

    pressure to the lesion, which can be useful in

    distinguishing erythema secondary to vasodilation

    (blanchable with pressure), from erythrocyte

    extravasation (retains its red color)

    Purpura may result from hyper- and hypo-

    coagulable states, vascular dysfunction and

    extravascular causes

  • Examples of Purpura

    Petechia

    Ecchymosis

  • Examples of Purpura

    Ecchymoses

    Petechiae

  • Mr. Chad Fields

    Case One

  • Case One: History

    HPI: Mr. Fields is a 42 year-old gentleman who presents to the ER with a 2-week history of a rash on his abdomen and lower extremities.

    PMH: hospitalization 1 year ago for community acquired pneumonia

    Medications: none

    Allergies: none

    Family History: unknown

    Social History: marginally housed, no recent travel or exposure to animals

    Health Related Behaviors: smokes 10 cigarettes/day, drinks 3-10 beers/day, limited access to food

    ROS: easy bruising, bleeding from gums, overall fatigue

  • Case One: Exam

    Perifollicular petechiae

    Keratotic plugging of hair follicles

  • Case One: Exam

    Mr. Fields also has

    hemorrhagic gingivitis

  • Case One, Question 1

    Which of the following is the most likely

    diagnosis?

    a. drug hypersensitivity reaction

    b. urticaria

    c. vasculitis

    d. rocky mountain spotted fever

    e. nutritional deficiency

  • Case One, Question 1

    Answer: e

    Which of the following is the most likely diagnosis?

    a. drug hypersensitivity reaction (typically without purpuric lesions)

    b. urticaria (would expect raised edematous lesions, not purpura)

    c. vasculitis (purpura would not be perifollicular and would be palpable)

    d. rocky mountain spotted fever (no history of travel or tick bite)

    e. nutritional deficiency

    http://missinglink.ucsf.edu/lm/DermatologyGlossary/drugeruption.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/urticaria.html

  • Vitamin C Deficiency - Scurvy

    Scurvy results from insufficient vitamin C intake (i.e. fad diet, alcoholism), increased vitamin requirement (i.e. certain medications), and increased loss (i.e. dialysis)

    Vitamin C is required for normal collagen structure and its absence leads to skin and vessel fragility

    Characteristic exam findings include: perifollicular purpura

    large ecchymoses on the lower legs

    intramuscular and periosteal hemorrhage

    keratotic plugging of hair follicles

    hemorrhagic gingivitis (when patient has poor oral hygeine)

    Remember to take a dietary history in all patients with purpura

  • Case Two

    Mr. Andrew Thompson

  • Case Two: History

    HPI: Andrew is a 19 year-old gentleman who was admitted to the hospital with a headache, stiff neck, high fever, and a rash. His symptoms began 2-3 days prior to admission when he developed fevers with nausea and vomiting.

    PMH: splenectomy 3 years ago after a snowboarding accident

    Medications: none

    Allergies: none

    Vaccination hx: last vaccination as a child

    Family history: not contributory

    Social history: attends a near-by state college, lives in a dormitory

    Health related behaviors: reports occasional alcohol use on the weekends with 2-3 drinks per night, plays basketball with friends for exercise.

    ROS: as mentioned in HPI

  • Case Two: Exam

    Vitals: T 102.4 F, HR 120, BP 86/40, RR 20, O2 sat 96% on room air

    Gen: ill-appearing male lying on a gurney

    HEENT: PERRL, EOMI, + nuchalrigidity

    Skin: petechiae and large ecchymotic patches on upper (not shown) and lower extremities = Purpura fulminans

  • Case Two: Initial Labs

    WBC count:14,000 cells/mcL

    Platelets: 100,000/mL

    Decreased fibrinogen

    Increased PT, PTT

    Blood Culture: gram negative diplococci

    Lumbar puncture: pending

  • Case Two, Question 1

    In addition to fluid resuscitation, what is the

    most needed treatment at this time?

    a. Plasmapheresis

    b. IV antibiotics

    c. Pain relief with oxycodone

    d. IV corticosteroids

  • Case Two, Question 1

    Answer: b

    In addition to fluid resuscitation, what is the most needed treatment at this time?

    a. Plasmaphoresis (not unless suspecting diagnosis of TTP)

    b. IV antibiotics (may be started before lumbar puncture)

    c. Pain relief with oxycodone (not the patients primary issue)

    d. IV corticosteroids (not unless suspicion for pneumococcal meningitis is high)

  • Sepsis and DIC

    Andrews clinical picture is concerning for meningococcemia with disseminated intravascular coagulation (DIC)

    Presence of petechial or purpuric lesions in the patient with meningitis should raise concern for sepsis and DIC

    Neisseria meningitis is a gram negative diplococcus that causes meningococcal disease Most common presentations are meningitis and

    meningococcemia

    DIC results from unregulated intravascular clotting resulting in depletion of clotting factors and bleeding The primary treatment is always to treat the underlying condition

  • Rocky Mountain Spotted Fever

    Another life-threatening diagnosis to consider in a patient with a petechial rash is Rocky Mountain Spotted Fever (RMSF)

    The most commonly fatal tickborne infection (caused by Rickettsia rickettsii) in the US

    A petechial rash is a frequent finding that usually occurs several days after the onset of fever

    Initial appearance of the rash is characterized by faint macules on the wrists or ankles. As the disease progresses, the rash may become petechial and involves the trunk, extremities, palms and soles

    Majority of patients do not have the classic triad of fever, rash and history of tick bite

  • Clinical Evaluation of Purpura

    A history and physical exam is often all that is necessary

    Important history items include: Family history of bleeding or thrombotic disorders (ie von

    Willebrand disease)

    Use of drugs and medications (i.e. aspirin, warfarin) that may affect platelet function and coagulation

    Medical conditions (i.e. liver disease) that may result in altered coagulation

    Complete blood count with differential and PT/PTT are used to help assess platelet function and evaluate coagulation states

  • Causes of Non-Palpable Purpura

    Petechiae

    Thrombocytopenia

    Idiopathic

    Drug-induced

    Thrombotic

    DIC and infection

    Abnormal platelet function

    Increased intravascular

    venous pressures

    Some inflammatory skin

    diseases

    Ecchymoses

    External trauma

    DIC and infection

    Coagulation defects

    Skin weakness/fragility

    Waldenstrom

    hypergammaglobulinnemi

    c purpura

  • Palpable Purpura

    Palpable purpura results from inflammation of

    small cutaneous vessels, ie vasculitis

    Vessel inflammation results in vessel wall damage

    and in extravasation of erythrocytes seen as

    purpura on the skin

    Vasculitis may occur as a primary process or may

    be secondary to another underlying disease

    Palpable purpura is the hallmark lesion of

    leukocytoclastic vasculitis (small vessel vasculitis)

  • Vasculitis Morphology

    Vasculitis is classified by the vessel size affected (small,

    medium, mixed size or large)

    Clinical morphology correla

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